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Opals Respiratory

Stiell IG, Wells GA, De Maio VJ, Nesbitt L, Martin MT, Brisson D, Cousineau D, Doherty J, Beaudoin T, Vaillancourt C, Spaite DW, Nichol G, Lyver MB, Field BJ, Munkley DP, Luinstra LG, Campeau T, Dagnone E, Maloney JP, Easo J, Blackburn J, Huszti E.

Multicenter Controlled Clinical Trial to Evaluate the Impact of Advanced Life Support on Out-Of-Hospital Respiratory Distress Patients. (Abstract)Presented at the Society for Academic Emergency Medicine, St. Louis, MO, May 2002.

OBJECTIVES: There is little published evidence regarding the optimal EMS management of respiratory distress. Our study evaluated the impact of advanced life support (ALS) EMS programs on respiratory patient outcomes

METHODS: This multicenter before-after controlled clinical trial was conducted in 20 communities (population 15,000 to 750,000) as part of the Ontario Prehospital Advanced Life Support (OPALS) Study, which evaluates the impact of EMS programs for multiple conditions. During the before phase, care was provided at the BLS-D level. During the after phase, ALS providers performed endotracheal intubation and administered nebulized and IV drugs. Data were collected from ambulance reports, centralized dispatch data, ED records, and in-hospital records. Chi-square and Student's t-test analyses were performed.

RESULTS:  The 7,716 patients enrolled during the two 6-month BLS and ALS phases were well matched for clinical and demographic features and had these characteristics: mean age 74.0 (16-107), female 53.6%, EMS status 'severe/life threatening' 51.8%, mean RR 28, final hospital diagnoses: CHF 16.9%, COPD 16.3%, pneumonia 9.8%, asthma 5.7%, other cardiac 4.8%, CHF/COPD 3.4%, cancer 2.9%. During the ALS phase, patients received these EMS interventions: nebulized salbutomol 55.3%, IV furosemide 15.2%, SL NTG 9.6%, IV morphine 1.5%, intubation 1.2%. There was a 23.4% relative reduction in the primary outcome, overall mortality, from the BLS to the ALS phase (15.4% vs 11.8%; P<.001). This table compares other outcomes:

MEASUREMENT BLS ALS P-VALUE:

EMS-judged 'improved' 24.6% 46.7% .0001
ED mortality 1.2% 0.9% .0001
ED intubation 4.9% 3.5% .001
CXR Aspiration 4.4% 1.8% .001
Length of stay, days 10.2 9.3 .05
Best CPC at discharge 42.6% 58.7% .0001

CONCLUSIONS:  This is the largest controlled trial of out-of-hospital respiratory distress patients and clearly shows important benefit from ALS programs for mortality and other outcomes.